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The client from a long-term care facility is admitted to the medical unit with a fever, hot flushed skin, and clumps of white sediment in the indwelling catheter. Which intervention should the nurse implement first?
- A. Start an IV with a 20-gauge catheter.
- B. Initiate antibiotic therapy IVPB.
- C. Collect a urine specimen for culture.
- D. Change the indwelling catheter.
Correct Answer: C
Rationale: Symptoms suggest a catheter-associated UTI. Collecting a urine culture first identifies the causative organism, guiding antibiotic therapy. Starting an IV, antibiotics, or changing the catheter are secondary to obtaining a diagnostic sample.
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Which nursing diagnosis is priority for the client who has undergone a TURP?
- A. Potential for sexual dysfunction.
- B. Potential for an altered body image.
- C. Potential for chronic infection.
- D. Potential for hemorrhage.
Correct Answer: D
Rationale: Hemorrhage is the priority post-TURP due to the risk of significant bleeding from the surgical site, which can be life-threatening. Sexual dysfunction, body image, and infection are secondary concerns.
Which nursing intervention is most helpful in assisting the client undergoing hemodialysis to cope with the treatment?
- A. Giving the client literature to read about renal failure
- B. Advising the client's spouse to cook the client's favorite dishes
- C. Keeping the client informed of the latest research findings
- D. Exploring with the client how this disorder has affected life
Correct Answer: D
Rationale: Exploring the impact of the disorder on the client's life fosters emotional coping and supports psychosocial adjustment.
When the nurse inspects the client's urine specimen, which finding best indicates that the urine contains red blood cells?
- A. The urine appears cloudy.
- B. The urine appears smoky.
- C. The urine appears bright orange.
- D. The urine appears dark yellow.
Correct Answer: B
Rationale: Smoky urine is indicative of hematuria (red blood cells in the urine), a common finding in glomerulonephritis due to kidney inflammation.
The client is admitted to a nursing unit from a long-term care facility with a hematocrit of 56% and a serum sodium level of 152 mEq/L. Which condition is a cause for these findings?
- A. Overhydration.
- B. Anemia.
- C. Dehydration.
- D. Renal failure.
Correct Answer: C
Rationale: Elevated hematocrit (56%) and hypernatremia (152 mEq/L) indicate dehydration, which concentrates blood components and sodium. Overhydration dilutes these values, anemia lowers hematocrit, and renal failure typically causes hyponatremia.
The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a medical floor. Which nursing task is most appropriate for the nurse to delegate?
- A. Collect a clean voided midstream urine specimen.
- B. Evaluate the client’s eight (8)-hour intake and output.
- C. Assist in checking a unit of blood prior to hanging.
- D. Administer a cation-exchange resin enema.
Correct Answer: A
Rationale: Collecting a clean voided midstream urine specimen is a task within the UAP’s scope, as it involves following a standard procedure. Evaluating intake/output, checking blood, or administering enemas require nursing judgment or specialized training, making them inappropriate for delegation.